A 56-year-old man comes to the emergency department with retrosternal chest pain that began when he was cleaning his backyard a few hours ago. His medical problems include type 2 diabetes mellitus, hypertension, hypercholesterolemia, and obesity. Three weeks ago, his hemoglobin A1C was 9.6% and glyburide was added. He has no overt chronic complications of diabetes. His medications include metformin, glyburide, ramipril, amlodipine, simvastatin, and low-dose aspirin.
His blood pressure is 140/80 mm Hg, pulse is 70/min, and body mass index is 38 kg/m². The patient appears a little apprehensive, but the examination otherwise shows no abnormalities.
Electrocardiogram shows normal sinus rhythm and non-specific ST-T changes in the lateral chest leads. The initial levels of cardiac troponin I are normal. Chemistry profile is normal except for blood glucose of 266 mg/dL. Chest x-ray is unremarkable.
The patient is admitted to a telemetry bed for monitoring, and serial cardiac enzymes are ordered. He is allowed to eat a diabetic diet. Finger-stick blood glucose measurement before meals and bedtime is ordered.
Which of the following is the best way to manage this patient's diabetes mellitus during hospitalization?

Question

Quizplus · Accepted Answer

Glycemic control in hospitalized diabetic patients can be affected by acute stress, change in nutrition, interruption of diabetic therapy, infection, and physical inactivity. The goals for inpatient diabetics are pre-meal blood glucose < 140 mg/dL and random glucose < 180 mg/dL in non-critically ill patients. Guidelines suggest glucose of 140-180 mg/dL in critically ill patients. Patients with adequately controlled blood glucose prior to admission can continue the same regimen (insulin or oral) while in the hospital. However, metformin should be stopped as it can cause lactic acidosis in conditions such as impaired renal function, concurrent liver disease, alcohol abuse, heart failure, and hemodynamic instability. Patients also tend to eat less while in the hospital and should lower their medication dose (oral secretagogues or insulin therapy) to prevent hypoglycemia. This patient and others with uncontrolled glucose prior to admission should discontinue their home regimen and start insulin. Insulin therapy consists of 3 forms: basal, prandial, and correctional. All 3 are usually required to control blood glucose in patients who can eat (eg, basal bolus regimen). Those without oral intake typically require both basal and correctional forms to control blood glucose. Therefore, this patient should stop oral medications and start on the basal bolus regimen (Choices A and B). (Choice D) Insulin infusion is required for critically ill patients. (Choice E) Studies have shown that sliding-scale insulin regimens administered alone were associated with a threefold increased risk of hyperglycemic episodes as compared with no therapy. Educational objective: Most hospitalized patients with diabetes mellitus require insulin to achieve optimal glycemic control. Basal bolus regimen (consisting of basal, prandial, and correctional insulin forms) is the best option for hospitalized diabetic patients who are allowed to eat their meals. __________ References: Inpatient treatment of type 2 diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/22833757)

A 56-Year-Old Man Comes to the Emergency Department with Retrosternal